Missing documentation and follow up in district nursing
Central London Community Healthcare NHS Trust received 2 coroners' reports about this hazard between 21 Feb 2020 and 6 Mar 2026.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“On 11 December 2019 the GP invited the District Nurses Team and Tissue Viability Nurses Team to attend a meeting at the surgery with the practice clinicians to review unexpected deaths and to discuss this case.”
Original on judiciary.uk ↗ Central London Community Healthcare NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“We have updated our Triaging Standard Operating Procedures to ensure a robust process for the management and response to referrals.”
- 6 years laterClosely relatedConfidence 0.85 · higha different coroner
“the initial assessment for Mr [name redacted] by the District Nurses did not record his next of kin details or what to do should the district nurse not be able to gain access.”
Original on judiciary.uk ↗ Repeated from the earlier report:DistrictNurses
Central London Community Healthcare NHS Trust responded.Response (PDF) ↗
- All reports to Central London Community Healthcare NHS Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2020 → 2026Asher Blackman6 years after Anita Loi · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth concerns involve failures in documentation and follow‑up processes within the District Nursing service that affect patient safety.
Anita Loi · 21 Feb 2020
“On 11 December 2019 the GP invited the District Nurses Team and Tissue Viability Nurses Team to attend a meeting at the surgery with the practice clinicians to review unexpected deaths and to discuss this case.”
Original on judiciary.uk ↗ Asher Blackman · 6 Mar 2026
“the initial assessment for Mr [name redacted] by the District Nurses did not record his next of kin details or what to do should the district nurse not be able to gain access.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We have updated our Triaging Standard Operating Procedures to ensure a robust process for the management and response to referrals.”
Stated action
“We have updated our Triaging Standard Operating Procedures to ensure a robust process for the management and response to referrals.”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Central London Community Healthcare NHS Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2020 → 2026 | 0.63 | 0.07 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.